Most third-party administrators (TPAs) of self-insured group health plans get the easy parts right:
- They apply the right deductibles and copays, the right coinsurance amounts, the right benefit maximums, etc.
- They rely on sophisticated electronic claims systems to help them pay claims accurately.
- Most group health plans are well documented.
- What happens if the system is set up incorrectly? Claims are systemically paid incorrectly.
- The Plan may be well documented; however, what happens when the TPA interprets Plan provisions that may not be clearly described? They apply their own administrative standard which may or may not be consistent with the Plan Sponsor’s intent.
- How do out-of-date systems affect accuracy? Billing errors may not be detected.
- Are out-of-network claims considered at reasonable billing rates? Maybe. Maybe not.
- Does the TPA comply with industry standards? Maybe. Maybe not.
- Does the TPA perform all of its duties effectively? Maybe. Maybe not.
- Has the Plan Sponsor demonstrated to its stakeholders that administrative due diligence has been performed?
Count on our expertise and experience to deliver superior audit results that answer these questions and more. Most audits result in cost-saving solutions for your health plan as well.